Transcription of APPLICATION FORM FOR ADDITION / DELETION
1 APPLICATION form FOR ADDITION / DELETION Employee Code 1. NO. OF cghs IDENTITY CARD 2. NAME OF THE GOVT. SERVANT 3. MINISTRY/OFFICE IN WHICH WORKING 4. NEW ADDITION / DELETION Name Date of Birth Relation 5. SIGNATURE OF GOVT. SERVANT / : _____ THUMB IMPRESSION. Date : 6. SIGNATURE AND DESIGNATION OF : _____ ISSUING AUTHORITY / SEAL 7. SIGNATURE OF MEDICAL OFFICER : _____ Note : form must be filled in triplicate along with the photographs and submit to Administration-I
